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Preventing work-related musculoskeletal disorders how variability between individuals can be better understood.This is important, since the aetiology of several MSDs is often not clear. For instance, for low back disorders on average 95% of the pain is called ‘nonspecific’ because the source of the pain is unknown and may have multiple causes. PREVENTION STRATEGIES As described in more detail elsewhere in this publication, the scientific knowledge resulting from different research studies can be used in the development of prevention strategies. It can help them to be both acceptable to the company and practical in terms of implementation so that practitioners are able to carry out effective risk assessments. Reducing physical demands is often the first preventive step to be taken at the workplace. This can mean making adjustments in the workplace, use of mechanical devices or aids with the aim to reduce the stresses imposed on the musculoskeletal system (e.g. wrist supports or mechanical handling devices). It is important to mention that MSDs are also found in jobs where the amount of force is reduced. Therefore, further attention has to be given to duration and frequency of exposure. Providing education and training is a further important strategy to reduce physical risks. Previous training efforts have generally fallen into three areas: 1. training of specific techniques; 2. teaching biomechanics, thus increasing the understanding and the awareness of the occurrence of MSDs so attitudes towards safe postures and movements can be changed; and 3. training the body via physical fitness so that it is less susceptible to injury. Paying attention to job design and work organisation can also contribute to prevention. One possible distinguishing feature of successful interventions, compared to those that have failed, is the extent to which intervention ownership is embedded in the company, including company management. It is also important to use measures that actively involve the worker. An important secondary prevention strategy is the carefully guided return-to-work (RTW) of the patient with a MSD, to stop the further development of a MSD or prevent the onset of chronic pain. A wellplanned RTW should incorporate a risk assessment and a control of hazardous job tasks or conditions to prevent re-injury and continued harm. Furthermore, proactive and employee-supportive communications in the workplace should be established. Health care EUROPEAN CONFERENCE CALLS FOR ACTION Many workplaces are designed for the physical characteristics of men rather than women, leaving women more prone to RSI-related complaints. Work-related musculoskeletal disorders cost about one per cent of the Gross National Product of Member States of the EU. And despite the number of studies on WRULDs, there remains considerable uncertainty, even controversy, about how to diagnose them. These are just some of the facts to emerge from an international conference on work-related upper limb disorders organised by the Dutch Ministry of Social Affairs and Employment held in The Hague on 30 May 2000. The conference was part of the Ministry’s response to the publication of the European Agency’s survey on Repetitive Strain Injuries in EU Member States carried out at their request. Conference participants were invited via the European Agency’s network of Focal Points. “It is precisely 10 years since the Directives on the minimum requirements for manual handling and visual display units were agreed but unfortunately the number of workers suffering from workrelated upper limb disorders is only rising,” said Rob Kuijpers, Director General of the Dutch Ministry of Social Affairs. The increase in WRULDs will have major economic consequences for European society unless it is stopped. If we do nothing, the problem will get worse, given also the enormous increase in the use of information and communication technology and the exposure of workers to to risk factors related to WRULDs, he said. According to Monique Frings, of the Medical Faculty of the University of Amsterdam: “Despite the number of studies on WRULDs, there is considerable uncertainty and even controversy about the criteria used to diagnose them.” An agreed definition would facilitate a more uniform collection, recording and reporting of information about WRULDs in the EU. Such an aim was adopted by a project funded by Saltsa, a joint programme for Working Life Research in Europe, the National Swedish Institute for Working Life and the Swedish Trade Unions in Co-operation, she said. It established a clinical diagnosis and assessed the work-relatedness of the diagnosis. Case definitions were formulated for 11 specific upper extremity disorders and for non-specific upper extremity disorders. Meanwhile, criteria on two types of work factors were provided: physical factors such as posture, movement and vibration and non-physical factors like work organisation and work characteristics. The conference heard from Theoni Koukoulaki of the European Trade Union Technical Bureau for Health and Safety (TUTB) that workers too often fail to make the connection between pain felt at work and the work which caused it. Moreover, compensation systems differ significantly between Member States, while official information systems on workplace diseases were reported as inadequate. Speaking on gender differences, Lena Karlqvist said: “Many workplaces are designed in such a way that they fit best with the physical characteristics of men”. Women are more likely to work in monotonous jobs involving repetitive work. They are less likely to be able to organise and control their work than men, making it more difficult for such women to cope with time pressures, she said (see article on this topic elsewhere in the magazine). Mr Jason Devereux from the University of Surrey presented information on the epidemiological evidence for WRULDs, noting that scientists have identified a strong relationship between WRULDs and the performance of work, especially where workers are exposed to workplace risk factors. In summary, the conference concluded that: • WRULDs are the most pervasive work-related health problem in the EU and they seem set to continue to be so for the next decade • WRULDs are increasingly prevalent in all sectors and occupations • WRULDs can be caused by a variety of activities and risk factors • Given the lack of success of the EU’s and member states’ policies to reduce the problem, new initiatives need to be undertaken to complement and develop existing strategies • The prevention of WRULDs should be a top priority in the next European action programme for safety and health at work • Member states should consider establishing national action plans to combat WRULDs. Such action plans, which need to be properly funded, should focus on preventative measures. Targets related to specific risk factors should be set and monitored for progress. 12
Preventing work-related musculoskeletal disorders interventions are another important part of secondary prevention. These interventions may include medication, exercise therapy,... Regarding the effectiveness of prevention strategies, there are dissenting views in the literature. The discrepancies are often attributed to the different methodological quality of the studies: lack of control groups, lack of randomisation, lack of a placebo group, small number of subjects, no standardisation of the environment, Other negative factors are high costs of interventions, lack of underlying commitment from workers or management. RESEARCH TOPICS/PRIORITIES Although we have already amassed valuable information and identified some consistent patterns from current research, additional research is necessary to provide a better understanding of the processes involved. The focus should be on several topics: risk factors, health outcome, exposure measurement, health surveillance and intervention. The National Research Council (1999) mentions five interrelated and fundamental issues that deserve attention: • develop further models and mechanisms to investigate how tissue responds to repetitive loading, what triggers inflammatory responses and how are these influenced by individual factors? • clarify the relationships between symptoms, injury reporting, impairment and disability and how are these relationships influenced by social, legal and environmental factors. Multiple factors have to be considered. • know more about the relationships between incremental changes of the environmental load and incremental responses to define more efficient and better-targeted interventions. • have more standardisation and greater detail in injury reports, better measurements of contributors and risks, and better measurements of outcomes and other relevant variables. • have a better understanding of the clinical courses of the disorders to assist strategies for tertiary prevention. KEY REFERENCES 1 European Agency for Safety and Health at Work 1999. Work-related neck and upper limb musculoskeletal disorders. Buckle P, Devereux J. 2 European Agency for Safety and Health at Work 2000. Work-related low back disorders. Op De Beeck R, Hermans V. 3 Hagberg M, Silverstein BA, Wells RV, Smith MJ, Hendrick HW, Carayon P, Pérusse M. Work related musculoskeletal disorders: a reference for prevention; Kuorinka I. & Forcier L (eds). London:Taylor & Francis, 1995. 4 National Research Council. Work-related musculoskeletal disorders: report, workshop summary, and workshop papers. Washington DC: National Research Council, 1999. 5 Wilson JR, Corlett EN. (eds). Evaluation of human work : a practical ergonomics methodology, Taylor & Francis : London, 1134 p. European Agency for Safety and Health at Work 13
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